MEDICATION AUTHORIZATION 2017

AUTHORIZATION FOR ADMINISTERING MEDICATIONS: Although we discourage the use of medication during program hours, should it become necessary for WTRC staff to facilitate day-time medications we must have the parents' authorization to do so.

Parents must attach this MEDICATION AUTHORIZATION form to the WTRC Participant Medical Form for EACH medicine their child will take during program hours.

(THIS INCLUDES ANY PARTICIPANT REQUIRING INHALER/MEDICATION FOR ANAPHYLAXIS)

NOTE TO PARENT/GUARDIAN: A SIGNED PHYSICIAN’S STATEMENT CONTAINING THIS INFORMATION MUST BE PROVIDED BEFORE THIS MEDICATION MAY BE ADMINISTERED.

Attach Signed Physician's Statement Here:
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Medication must be in the original container with the original label attached and labeled with the participant’s name on the label. Parent/guardian shall provide written instructions to WTRC staff concerning administration of medication. Written instructions will be valid for 6 months unless a shorter period is designated by the parent/guardian. The parent/guardian is responsible for submitting a new form each time there is a change in medication, dosage, or time the medication is to be administered. All documentation must be supported by a physician’s statement. The first dosage must be taken at home. The WTRC is not responsible for any unauthorized medication taken independently by the child.
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I understand that I am required to cooperate with WTRC with regard to the administration of my child’s medication. I understand that some medications cannot be administered by WTRC, and if my child requires such a medication, it is my responsibility to make arrangements for my child’s medication.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.